404.3 🩺 內科專科考前版

404.3.0.1 📌 䞀頁重點

  • 22E updates:
    • Oral testosterone undecanoate (Jatenzo, Tlando) approved (FDA 2019, 2022) — bypass first-pass; lipid + BP monitoring
    • Auto-injector SC (Xyosted) approved
    • Enclomiphene for hypogonadism with fertility preservation (FDA 2024)
    • Functional hypogonadism (obesity-related) — weight loss + lifestyle preferred over TRT
    • TRAVERSE trial 2023: TRT in older men with hypogonadism — non-inferior CV outcomes
  • Taiwan: 健保 IM testosterone undecanoate (Nebido); 健保 testosterone gel; oral undecanoate (Jatenzo) 自費 倚; 健保 cabergoline; 健保 TESE+ICSI for selected; CTAOH/TES + Endocrine Society 2018 hypogonadism guideline

404.3.0.2 🌟 Pearls (15)

  1. Total T < 264 ng/dL (Endocrine Society 2018 cutoff) for hypogonadism diagnosis (lab-specific)
  2. Free testosterone important when SHBG abnormal (obesity ↓ SHBG; aging ↑ SHBG)
  3. TRAVERSE trial 2023: TRT not inferior for major CV events in hypogonadal men with CV risk
  4. Functional hypogonadism in obesity: weight loss reverses ~ 50% — consider before TRT
  5. OSA + TRT: monitor; severe OSA may worsen
  6. TRT erythrocytosis: 24% risk in IM; less in gel; Hct trend matters
  7. Enclomiphene (clomiphene isomer) preserves fertility while raising T
  8. HCG monotherapy for fertility-preserving in central hypogonadism
  9. TESE + ICSI: ~ 50% sperm retrieval in Klinefelter; earlier intervention better
  10. Anabolic steroid abuse: epidemic; long-term azoospermia possible; recovery 6-24 mo
  11. Anti-doping panel: T:E ratio, hCG, LH/FSH suppressed
  12. Aromatase inhibitor (anastrozole) for select gynecomastia / fertility 偶 used (off-label)
  13. Clomiphene for male infertility: ↑ T + LH/FSH; off-label
  14. Iron overload (hemochromatosis): pituitary + testis dual; phlebotomy + replacement
  15. Late-onset hypogonadism (LOH): controversial diagnosis; treat only if severe biochemical + symptomatic

404.3.0.3 📍 Taiwan + 健保

404.3.0.3.1 TRT Formulations
  • 健保 testosterone undecanoate IM (Nebido) 1000 mg q10-14 wk 條件 (proven hypogonadism)
  • 健保 testosterone gel (Tostran, AndroGel) 條件
  • 健保 testosterone enanthate IM (older; less common)
  • Oral testosterone undecanoate (Jatenzo, Tlando) 自費 倚
  • Pellets not commonly used Taiwan
404.3.0.3.2 Lab + Workup
  • 健保 testosterone (total + free; total 范廣)
  • 健保 LH, FSH, prolactin
  • 健保 SHBG (條件)
  • 健保 estradiol (條件)
  • 健保 karyotype (Klinefelter 條件)
  • 健保 MRI sella (條件)
  • 健保 semen analysis 條件
404.3.0.3.3 Fertility
  • 健保 hCG + FSH (gonadotropin therapy) 條件 (限制䞭心)
  • 健保 TESE + ICSI (assisted reproduction; selected covered, others self-pay)
  • Sperm cryopreservation 倚 self-pay
404.3.0.3.4 ED
  • PDE5 inhibitor:
    • Sildenafil 健保 條件 (limited indications)
    • Tadalafil 健保 + 自費
    • Vardenafil, avanafil 自費 倚
  • 健保 vacuum erection device (條件)
  • 健保 intracavernosal alprostadil (條件)
  • 健保 penile prosthesis (條件)
404.3.0.3.5 Gynecomastia
  • 健保 tamoxifen (off-label, 條件)
  • 健保 surgical reduction (cosmetic 自費 倚)
404.3.0.3.6 孞會 + 指匕
  • TES 內分泌孞會 + Endocrine Society Hypogonadism 2018
  • AUA Male Hypogonadism + ED Guideline
  • ASRM Male Infertility

404.3.0.4 🎓 內專必懂 (15)

  1. HPG axis male + feedback
  2. Primary vs central hypogonadism distinction
  3. Hypogonadism etiology comprehensive
  4. Total + free testosterone + SHBG considerations
  5. TRT indication + formulations + monitoring
  6. TRT contraindications (CA, OSA, Hct)
  7. TRT vs fertility (gonadotropin alternative)
  8. Functional hypogonadism (obesity) + weight loss reversal
  9. Klinefelter management lifelong
  10. Kallmann + IHH (Kallmann typical, isolated GnRH def)
  11. Gynecomastia workup + tamoxifen
  12. ED workup + PDE5 + alternatives
  13. Cryptorchidism orchiopexy + cancer surveillance
  14. Anabolic steroid abuse recognition + recovery
  15. 22E new: oral T undecanoate, enclomiphene, TRAVERSE, auto-injector

404.3.0.5 ⚙ Hypogonadism Treatment Decision Tree (內專)

Step 1 — Confirm hypogonadism:
- AM total testosterone × 2 separate days < 264 (Endocrine Society) or < 300 ng/dL (lab variable)
- Symptomatic
- Free T if SHBG abnormal

Step 2 — Determine etiology:
- LH/FSH high → primary
- LH/FSH low/normal → central (workup MRI sella + PRL + iron + meds)

Step 3 — Reverse functional causes if possible:
- Weight loss for obesity (T can normalize)
- Address OSA, sleep
- Reduce/stop opioid, anabolic, glucocorticoid
- Treat prolactinoma, hemochromatosis
- Address comorbidity (T2DM optimization)

Step 4 — Fertility considerations:
- Want children NOW or imminent: 䞍 TRT
  - Use hCG (1500-3000 IU SC 2-3x/wk) + recombinant FSH (75-150 IU 3x/wk) for central
  - Use clomiphene 25-50 mg/d for primary or central
  - Use enclomiphene (newer, FDA 2024) for fertility-preserving T elevation
- Done with childbearing or 䞍 fertile concern: TRT acceptable

Step 5 — TRT initiation:
- Choice of formulation (patient preference, cost, lifestyle)
- Baseline: Hct, PSA, BMD, lipid, LFT
- Titrate to mid-normal T

Step 6 — Monitoring:
- 3-6 mo: T, Hct, symptoms
- Annual: T, Hct, PSA, BMD, lipid

Step 7 — Adverse events:
- Hct > 54%: phlebotomy or hold
- PSA > 1.4 ng/mL/yr rise: urology
- OSA worsening: titrate or stop
- Skin reaction (gel/patch): rotate
- Pain (IM): switch
- Lipid: monitor + manage

404.3.0.6 ⚙ Klinefelter Lifelong Management

Diagnosis:
- 47,XXY (~80%) or mosaic
- Often delayed (adulthood)
- Small firm testes, T low, FSH/LH high

Adolescence:
- Testosterone replacement starting puberty (12-14 yr)
- Bone density baseline
- TESE+ICSI for fertility (best in 14-30 yr; sperm retrieval declines)

Adult:
- Lifelong TRT
- Bone density q1-2 yr
- Lipid + glucose + MetS
- Breast cancer screening (~ 20x risk)
- Autoimmune (RA, SLE) surveillance
- Cardiometabolic (DM, CV) risk modification
- Cognitive support if needed
- Mental health screening
- Periodic BP

Family + Support:
- Genetic counseling
- Mental health resources
- Educational/vocational support

404.3.0.7 ⚙ Anabolic Steroid Abuse Recovery (內專)

Recognition:
- Suppressed LH/FSH/T despite muscle/build
- Detectable T:epitestosterone ratio (anti-doping)
- Acne, gynecomastia (paradoxical from aromatization), male pattern hair loss
- Cardiomyopathy, dyslipidemia, hepatotoxicity
- Aggression, mood swings ("roid rage")

Recovery Protocol:
- Stop anabolic steroid (acute discontinuation OK)
- HCG (1500-3000 IU SC 3x/wk) to stimulate Leydig recovery
- Clomiphene 25-50 mg/d to stimulate HPG
- Aromatase inhibitor (anastrozole 0.5-1 mg/d) if estradiol elevated
- Symptomatic management (mood, body)
- Monitor T, LH/FSH, sperm count
- 6-24 mo recovery typical
- Some æ°žä¹… hypogonadism (rare with severe long-term use)

⚠ AI 草皿。